Hospitals have been in turmoil during the past decade as a result of extreme financial pressures, changing views of their roles (see Shortell, Gillies, and Devers 1995), and a general reassessment of the responsibilities of nonprofit organizations. Every week, it seems, there is news of a significant merger, an acquisition, or a hospital closing.

Whereas hospitals were once largely independent organizations, they now tend to be part of larger integrated delivery systems. The first section of this issue of the Quarterly comprises three articles that address aspects of this changing landscape.

Jeffrey A. Alexander, Bryan J. Weiner, and Melissa Succi, authors of “Community Accountability among Hospitals Affiliated with Health Care Systems,” examine a national sample of hospitals to assess how hospitals affiliated with larger health care systems maintain “community accountability” by addressing the needs of people in their local communities. The results of their study indicate that system-affiliated hospitals do serve their communities, but in different ways than free-standing hospitals. Both types of hospitals are highly variable in how much they address community needs. The practical implications of these study findings are that policies should be shaped in ways that encourage more responsiveness to the community. Furthermore, communities should consider characteristics of particular systems when they make decisions about the potential affiliations of area hospitals.

Nonprofit hospitals do not pay taxes, and many think that, for this reason, they should they provide extra community services benefits for which they are not paid, especially care for the uninsured. There is considerable controversy, however, about whether communities receive benefits that are commensurate with the tax exemption they offer. Nancy M. Kane and William H. Wubbenhorst examined the relation between the value of tax exemptions received by hospitals and the amount of free care they provide, and they report their findings in “Alternative Funding Policies for the Uninsured: Exploring the Value of Hospital Tax Exemption.” According to Kane and Wubbenhorst, the value of the free care provided by most hospitals is usually not equal to the amount of tax exemption they receive, and hospitals in poorer communities provide relatively more free care than other hospitals. The authors suggest several types of policies that would encourage hospitals to provide free care at a more appropriate level.

The Roman Catholic Church sponsors a distinctive group of nonprofit hospitals. In the early part of the century, Catholic hospitals had unique characteristics and were operated primarily by Catholics, both lay persons and members of religious organizations. Over time, however, the staff and operation of Catholic hospitals have come to resemble those of other hospitals in certain ways. In this issue, Kenneth R. White, in his article entitled “Hospitals Sponsored by the Roman Catholic Church: Separate, Equal, and Distinct?,” examines the motivation and justification for Catholic hospitals and assesses whether they are, in fact, distinct from other nonprofit hospitals. He concludes that, in order to justify a distinct social role and to survive as a separate type of organization, Catholic hospitals must define and demonstrate their unique role and contribution.

Although hospitals will always play a prominent role in the U.S, health care system, we are now recognizing that preventive and ambulatory care and management of chronic illness should have a higher priority than has been the case in the past. Many determinants of health and illness are social (see entire issue of the Milbank Quarterly 76[3], 1998). As we struggle to reduce the consequence of poor health, we are gaining a new appreciation of the importance of prevention. Frequently, diverse types of local organizations collaborate to address health issues in their community. These alliances, often referred to as Community Health Partnerships (CHPs), face unique governance and management challenges. Shannon M. Mitchell and Stephen M. Shortell, authors of “The Governance and Management of Effective Community Health Partnerships: A Typology for Research, Policy, and Practice,” assess the literature on CHPs and analogous organizations and develop a typology of CHPs that can be used by researchers and policy makers to identify the difficulties faced by CHPs, guide their development, and sustain their success

There are many theories about why socioeconomic conditions are so strongly related to health status. One of the most straightforward hypotheses is that because persons with fewer economic resources are less likely to have health insurance, they are more likely to receive inadequate health care and hence to have lower health status than insured persons. Catherine E. Ross and John Mirowsky, in their article “Does Medical Insurance Contribute to Socioeconomic Differentials in Health?,” analyzed data from the Aging, Status, and Sense of Control Survey, a panel study of U.S. adults, and found that the health status of persons with private insurance and without any insurance was comparable. However, and unexpectedly, persons covered by public insurance reported significantly worse health than the uninsured. This difference was not due to the amount of care received. Medicaid patients in this study, for example, visited their doctor more often and received more drugs than the uninsured. Ross and Mirowsky speculate that Medicaid recipients may be less likely to receive other types of care, such as advice about nutrition and exercise.

The past few years have produced considerable debate in Congress about how best to allocate human organs to persons in need of a transplant. One motivating factor in this debate is the insufficient number of organs relative to the numbers of people who could benefit from transplantation. Surprisingly little research has been done on how to increase the donation rate (see Dejong, Drachman, and Gortmaker 1995). In this issue of the Quarterly, Thomas May, Mark P. Aulisio, and Michael A. DeVita note, in “Patients, Families, and Organ Donation: Who Should Decide?,” that although the majority of U.S. adults say they would willingly donate their organs after death, half of the families that are asked to honor the bequest of their loved ones do not consent to the procedure. The authors examine the policy devised by the Center for Organ Recovery and Education of acting on the eligible individuals’ documented wishes to donate tissue and organs, independent of family preferences, and conclude that this policy is justified. At a time when there is so much controversy about how to allocate scarce organs, May and his colleagues argue that adopting this approach more generally could alleviate the existing shortage.

In the last issue, I announced that on July 1, 2000, Bradford H. Gray, PhD, becomes the editor of the Milbank Quarterly. Authors should now send manuscripts to:

Bradford H. Gray, PhD
Director, Division of Health and Science Policy
New York Academy of Medicine
1216 Fifth Avenue
New York, NY 10029-5293

Brad has published extensively on topics of interest to many readers of the Quarterly, including the ethics of human experimentation in for-profit and nonprofit health care, the changing conditions of medical professionalism, and managed care. His current research is concerned with managed care, safety-net institutions, and ownership issues in health care, including the sale of nonprofit institutions to for-profit companies. This breadth of vision and experience makes him an ideal person to guide and shape the Quarterly in future years. I am always eager to receive suggestions from readers about how to improve the Quarterly, but the transition of editors is an especially opportune time to consider changes in emphasis or procedures. Thus, I encourage anyone with suggestions to write to either Brad or me with ideas and suggestions

Paul D. Cleary

Author(s): Paul D. Cleary

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Volume 78, Issue 2 (pages 153–156)
DOI: 10.1111/1468-0009.00041-i3
Published in 2000